A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

Hypertension

Unequal pupils

Confusion

Tympany upon chest percussion

Answer and Explanation

The Correct Answer is C

A. Hypertension is not typically associated with pneumonia, especially in older adults. Pneumonia can lead to hypotension or sepsis, but not usually hypertension.
B. Unequal pupils are not a typical finding associated with pneumonia. This could suggest a neurological issue or a possible eye problem, not a respiratory infection.
C. Confusion is a common sign of pneumonia in older adults, especially in the elderly, who may present with altered mental status due to hypoxia, infection, or dehydration. Delirium or confusion is a common manifestation of pneumonia in this population.
D. Tympany on chest percussion suggests air in the abdominal cavity, not in the lungs, and is not typically associated with pneumonia. Pneumonia is more likely to present with dullness upon percussion due to consolidation in the lungs.

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Correct Answer is B

Explanation

A. Clubbing of the fingernails is typically a sign of chronic hypoxia and is seen in conditions like cystic fibrosis, COPD, and other respiratory or cardiovascular diseases. It is a long-term issue and does not indicate an immediate emergency.
B. Tracheal deviation is a medical emergency and typically indicates tension pneumothorax, where air accumulates in the pleural space, shifting the trachea away from the affected side. This can compress the heart and lungs, leading to respiratory and circulatory collapse, requiring immediate action.
C. Contraction of the diaphragm may refer to normal breathing mechanics and does not indicate an immediate emergency unless it is associated with respiratory distress or failure.
D. Rhonchi are abnormal lung sounds often associated with mucus in the airways and can be heard in conditions like bronchitis or COPD. Although they may require attention, they do not represent an immediate emergency compared to tracheal deviation.

A. Sitting upright with elbows on an over-bed table and feet supported B. Sitting in bed with knees slightly flex and feet flexed C. Lying flat in the fetal position on the unaffected side D. Lying flat on the unaffected side with knees slightly flexed

Correct Answer is A

Explanation

A. The optimal position for a thoracentesis is sitting upright with the patient leaning forward slightly, with elbows resting on an over-bed table to help expose the pleural space for access. This position allows gravity to pull the lungs downward and facilitates easier access to the pleural cavity.
B. Sitting in bed with knees slightly flexed and feet flexed is not the best position for thoracentesis. This position might limit the ability to properly expose the thoracic cavity for the procedure.
C. Lying flat in the fetal position on the unaffected side would not allow for effective drainage or access to the pleural space and is not ideal for thoracentesis.
D. Lying flat on the unaffected side with knees slightly flexed is not ideal because it does not provide optimal positioning for the procedure. The upright position is preferred for thoracentesis to facilitate easy access to the pleural space.

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A nurse in the emergency department is assessing an older adult client who has community-acquired pneumonia. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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